Labial salivary gland biopsy in Sjögren's syndrome. Assessment as a diagnostic criterion in 362 suspected cases

Relationship between sialographic findings of parotid glands and histopathologic finding of labial glands in Sjögren's syndrome. Relation to clinical and immunologic findings

We investigated a relationship between sialographic findings of parotid glands and histopathologic changes of labial glands, in relation to Sjögren's syndrome. We examined 107 patients, suspected to have Sjögren's syndrome because of dry mouth and dry eyes, in whom no other autoimmune diseases were diagnosed. Parotid sialography identified 37 patients with punctate, globular, cavitary, or destructive sialectasia (S-positive group). These sialographic findings were not seen in the other 70 patients (S-negative group). Among these patients, 54 demonstrated periductal lymphocytic infiltration in the labial glands (H-positive group), whereas the other 53 patients did not demonstrate this histologic finding (H-negative group). Significant differences in stimulated parotid salivary flow rate and incidence of keratoconjunctivitis sicca were observed between patients in the S-positive and the S-negative groups. Differences in the salivary flow rate and the incidence of keratoconjunctivitis sicca were also seen between patients in the H-positive and the H-negative groups, although the differences were not statistically significant. The rate of incidence of serum rheumatoid factor, anti-SS-A, and anti-SS-B antibodies were significantly higher in the S-positive and the H-positive groups than in their negative counterparts.

A case of Sjögren's syndrome with repeatedly negative findings on lip biopsy

We report a case of Sjögren's syndrome characterized by keratoconjunctivitis sicca, parotid swelling, reduced salivary flow, and abnormalities on nuclear scanning. Two labial gland biopsies showed complete atrophy. Biopsy of an enlarged submandibular gland revealed lymphoid follicles and glandular replacement consistent with the diagnosis of Sjögren's syndrome. This case supports the concept that a negative finding on labial biopsy does not rule out a diagnosis of Sjögren's syndrome.

Histologic lesion in labial salivary glands of patients with systemic lupus erythematosus

In an attempt to evaluate the presence or incidence of Sjögren's syndrome in patients with systemic lupus erythematosus (SLE), 72 randomly selected patients with SLE, regardless of sicca manifestations, underwent labial salivary gland biopsy. Thirty-seven patients (51%) had normal labial salivary gland tissue. Seventeen patients (24%) had a mild perivascular infiltration of 15 to 20 lymphocytes per focus. In the remaining 18 patients (25%) heavy infiltration of more than 50 lymphocytes per focus was observed. From the latter group five specimens showed perivascular distribution of the infiltrates. About 40% of patients with any infiltration had keratoconjunctivitis sicca. Patients with severe lymphocytic infiltration in minor salivary gland tissue rarely had kidney involvement and often had lymphadenopathy and circulating rheumatoid factor, cryoglobulins, and antibodies to SS-A (Ro) and SS-B (La) antigens. Vasculitis was not found more frequently in any group of patients. Our results suggest that perivascular lymphocytic infiltrates in the labial salivary glands of patients with SLE may be the initial histologic lesion of Sjögren's syndrome.

Periductal lymphocytic infiltration of salivary glands in Sjögren's syndrome with relation to clinical and immunologic findings

We studied 113 patients who were suspected to have Sjögren's syndrome (SS) because they had dry mouth and dry eyes, and who were determined as not having any other autoimmune disease, to clarify the relationship of periductal lymphocytic infiltration of salivary glands to clinical and immunologic findings in relation to SS. Periductal lymphocytic infiltrations were observed in the labial and/or the parotid glands of 57 patients (P-group). The salivary glands of the other 56 patients did not demonstrate obvious histologic changes (N-group). The stimulated salivary flow rate of parotid glands of the patients in both the P- and N-groups was significantly reduced when compared with healthy persons. However, no difference in the flow rate was observed between the P- and N-groups. In contrast, the percentage of patients in the P-group with keratoconjunctivitis sicca was significantly higher than that of patients in the N-group. Percentage of gamma-globulin fraction and IgG level in the sera of the patients in the P-group were both significantly higher than those in the N-group. The percentages of patients who demonstrated the serum rheumatoid factor, anti-SS-A, and anti-SS-B antibodies were also significantly higher in the P-group than in the N-group.

Pancreatic ductal morphology and function in primary Sjögren's syndrome

In six patients with primary Sjögren's syndrome defined with HLA-antigens and no clinical signs of pancreatitis, the pancreatic ductal morphology (as described by endoscopic retrograde pancreatography), serum pancreatic enzymes, and fecal fat excretion were examined and secretin test was carried out. Further, oral glucose tolerance test with concomitant determination of serum insulin and C-peptide were done. All patients had at least two pathological signs of exocrine function and/or ductal morphology. There was no evidence of endocrine malfunction. The findings are suggestive of the existence of a clinically silent pancreatitis, perhaps of autoimmune etiology.

Swallowing problems in rheumatoid arthritis

Twenty-nine female patients with definite or classical rheumatoid arthritis (RA) and 30 controls were investigated in order to evaluate oral symptoms, particularly xerostomia, and swallowing difficulties in RA by means of a questionnaire, physical examination, stimulated saliva secretion, labial salivary gland biopsy, esophageal manometry and laboratory blood tests. Xerostomia was reported by 6 patients (21%), compared with no-one in the control group. Four of these 6 patients had decreased stimulated saliva secretion, compared with 2 of the remaining 23 patients. Dysphagia was experienced by 8 patients (28%), compared with one control subject. Dysphagia was associated with disease severity. Esophageal manometry revealed a decrease of the amplitude of the peristaltic pressure complex in the proximal part of esophagus in the RA group, indicating dysfunction of the striated muscles. No correlation was found between dysphagia and esophageal manometry results.

Specific HLA-DQA and HLA-DRB1 alleles confer susceptibility to Sjögren's syndrome and autoantibody production

Primary Sjögren's syndrome (1. SS) is a systemic autoimmune disease characterized by lymphocytic infiltration of the salivary glands and autoantibody production. In order to identify genetic factors that play a role in pathogenesis and predict extent of disease, we used Southern blot and polymerase chain reaction (PCR) methods to detect polymorphisms of the HLA-DRB1 (DR), HLA-DRB3 (DRw52), and HLA-DQA1 genes among 75 Caucasoid 1. SS patients and 150 Caucasoid controls living in the same geographic region of Southern California. We found significantly increased frequency of HLA-DR3 (P less than .001), HLA-DW52a (P less than .001), and HLA-DQA4 (P less than .05), in comparison to normal controls. Also, an increased frequency of heterozygosity for HLA-DQA1/DQA4 (P less than .05) was present among 1. SS patients. Autoantibodies to SS-A and to SS-B were significantly associated with DR3 (P less than .001), HLA-DQA4, (P less than .05), and DQA4/DQA1 heterozygotes (P less than .01). Among the 1. SS patients, clinical and laboratory features such as hypergammaglobulinemia, symmetric peripheral neuropathy, and hypothyroidism were significantly associated with HLA-DR3 (P less than .01) but not with HLA-DR2 (P greater than .10). In comparison, 1. SS patients with leukocytoclastic vasculitis were more frequently HLA-DR2 (P less than .05). These results using PCR methods confirm and extend prior studies that have used serologic methods.

Association of labial salivary gland histopathology with clinical and serologic features of connective tissue diseases

Focal sialadenitis is now widely accepted as an objective criterion for the oral component of Sjögren's syndrome (xerostomia). We investigated the association between labial salivary gland histopathologic changes and the clinical and serologic features of 192 patients with suspected connective tissue disorders. A retrospective review of the medical records of all patients was performed, and historical, physical, laboratory, histologic, and roentgenographic data were abstracted. Each patient had undergone labial salivary gland biopsy as part of a rheumatologic evaluation. There were significant associations between positive findings on lip biopsy and the presence of keratoconjunctivitis sicca (P = 0.013), positive antinuclear antibodies (titer greater than or equal to 1:80) (P = 2 x 10(-8)), and positive Ro antibodies (P = 1 x 10(-8)). However, sicca symptoms and glandular enlargement were not statistically associated with positive findings on lip biopsy. Features predictive of a positive lip biopsy included Ro antibodies (P = 0.914), keratoconjunctivitis sicca (P = 0.700), and positive antinuclear antibodies (P = 0.590).

Mast cells in the labial salivary glands of patients with Sjögren's syndrome: a histochemical, immunohistochemical, and electron microscopical study

Mast cells in labial salivary glands obtained from patients with xerostomia with or without focal sialadenitis/Sjögren's syndrome were studied. There was no significant correlation between the intensity of local lymphocyte infiltration and the morphometrically analysed number of mast cells staining positive with toluidine blue. Histamine staining with heterologous 11C antiserum showed significantly fewer positive cells than staining with toluidine blue (mean (SD) 62 (10) v 138 (30)). This suggests heterogeneity of the mast cell population. Furthermore, there was a correlation between the focus score and the number of mast cells containing histamine. This suggests that the proliferation of mast cells containing histamine may be locally regulated by the immune inflammation, possibly through mediators from macrophages and fibroblasts. In contrast, the number of mast cells staining positive with toluidine blue could not be used as a marker of the degree of local inflammation. Although transmission electron microscopic analysis did not disclose signs of 'en masse' mast cell degranulation, mast cells may have a role in the local disease process.

Hodgkin's disease occurring in primary Sjögren's syndrome

A 57 year old woman with a 13 year history of mouth dryness, keratoconjunctivitis sicca, and recurrent bronchial infections presented with multiple lymphadenopathies. Histological diagnosis was Hodgkin's disease. B and T cell lymphomas are well known complications of Sjögren's syndrome. This case provides evidence that Hodgkin's disease may also be associated with this syndrome.

Localization of lysozyme mRNA in the labial salivary glands by in situ hybridization in Sjögren's syndrome

In this study, lysozyme mRNA in labial salivary glands has been localized with in situ hybridization technique using 35S-labeled hen lysozyme cDNA (cDNALZM) as a hybridization probe in normals and in patients with Sjögren's syndrome, 35S-DNALZM:mRNA hybrids were detected only in acinar serous cells, although lysozyme was identified in ductal cells using immunohistochemical techniques. Our results suggest that the serous acinar cells are the only site of lysozyme synthesis in small salivary glands. The presence of lysozyme in ductal cells may be a result of reabsorption from the saliva or concentration from the blood or surrounding tissues.

Parotid gland biopsy for investigation of xerostomia

A technique is described for biopsy of the parotid salivary gland under local anaesthesia, which has been undertaken for a series of 59 patients who presented with suspected inflammatory exocrinopathy. The procedure is reliable and is associated with negligible postoperative discomfort. The advantages of the technique suggest that parotid gland biopsy is an acceptable alternative to conventional lower lip biopsy of minor salivary glands in the investigation of xerostomia.

Characterization of peripheral blood and salivary gland lymphocytes in Sjögren's syndrome

Primary Sjögren's syndrome (SS) is an autoimmune disease resulting from lymphocyte infiltration of lacrimal and salivary glands (SG). This study was designed to investigate the peripheral blood (PBL) and SG lymphocytes in 14 patients with primary SS and control subjects. With the use of monoclonal antibodies, cells were stained to identify T-cells and T-cell subsets (T-helper and T-suppressor) and cells positive for HLA-DR antigen, whereas B cells were determined by the Smlg (surface membrane immunoglobulin) method. Lymphocytes in SG biopsy specimens were characterized by means of monoclonal antibodies and the immunoperoxidase technique. In the peripheral blood lymphocytes, there was a significant reduction in T cells and suppressor T cells. T lymphocytes and mostly helper T cells were predominant around the ducts and within the lymphocytic infiltrates in the minor SG biopsy samples of patients with SS. Suppressor T cells and B cells were found in fewer numbers, HLA-DR(+) cell populations had increased, and IgG- and IgA-bearing plasma cells were also present within the infiltrates. These results may contribute to our understanding of the immunopathogenesis of primary SS.

Biopsy of the lip and Sjögren's syndrome

The degree of focal chronic sialadenitis in a labial salivary gland biopsy specimen, expressed in terms of a semiquantitative focus score, is the best contemporary assessment of the salivary component in Sjögren's syndrome. A labial salivary gland focus score of greater than 1 focus per 4 mm2 serves as an acceptable threshold for the diagnosis.

The diagnostic uses of saliva

It is becoming increasingly apparent to investigators and clinicians in a variety of disciplines that saliva has many diagnostic uses and is especially valuable in the young, the old and infirm and in large scale screening and epidemiologic studies. The highly sensitive test procedures that are now commonplace makes it practical to quantitate, despite very low concentrations, a large number of hormones and drugs in saliva. Indeed, all steroids of diagnostic significance in routine clinical endocrinology can now be readily measured in saliva. Drug monitoring can include abusive as well as therapeutic agents. The concordance between anti HIV antibodies in saliva and serum has stimulated application to various other antiviral antibodies as well as to viral antigens per se. Saliva has found use as a diagnostic aid in an increasing number of clinical situations and in systemic diseases that can affect salivary gland function and composition such as Sjögren's syndrome, cystic fibrosis and diseases of the adrenal cortex. The list keeps growing.

Quantification of plasma cells in labial salivary glands: increased expression of IgM in Sjögren's syndrome

Plasma cells expressing IgG, IgA and IgM were quantified in labial salivary glands from patients with Sjögren's syndrome (SS) and compared with glands showing non-specific inflammatory changes and normal controls. In all glands the predominant isotype was IgA but in SS there was a significant increase in both the number and proportions of IgG and IgM positive cells (P less than 0.002). In particular, all SS cases contained greater than 10% IgM positive cells (mean = 26.8 +/- 15.5). The results suggest that accumulation of IgM positive plasma cells may be a specific finding in SS and support the concept that the glandular lesions may be a site of B-cell clonal expansion. Since most B-cell hyperproliferative states in SS, including lymphoma, are associated with synthesis of IgM simple quantification of plasma cells may have important diagnostic and prognostic significance.

Axonal polyneuropathy without vasculitis, follicular lymphoma and primitive sicca syndrome. A rare association

A woman suffering from primary Sjögren's syndrome developed sensitive neuropathy. The disease was further complicated by follicular lymphoma, an unusual albeit already described complication of Sjögren's disease. The clinical data suggest that mononuclear infiltration of the dorsal root ganglions could be at the origin of a sensitive neuropathy, inducing an axonal degeneration of the nerves.

Comparison of labial and sublingual salivary gland biopsies in the diagnosis of Sjögren's syndrome

This study was designed to compare labial and sublingual salivary gland biopsies in the diagnosis of Sjögren's syndrome (SS). Fourteen labial and 29 sublingual specimens were considered positive. There was a better correlation between infiltration of the ductal structure and the focus score in the sublingual salivary gland biopsy than in the labial salivary gland biopsy. Use of sublingual salivary gland biopsy as an additional diagnostic tool in SS is therefore suggested.

Signs and symptoms in the masticatory system in ten patients with mixed connective tissue disease

Ten patients with mixed connective tissue disease (MCTD) were examined for signs and symptoms in the masticatory system. The study included clinical, radiological, histological and immunohistochemical examinations. The status of the teeth and periodontium did not seem to differ from that found in the general Finnish population. All 10 patients showed clinical dysfunction, and 7 had additional radiographic changes of the temporomandibular joints. Sialopenia was observed in 7 patients, and histological examination revealed sialoadenitis with a focus score exceeding 1 in the labial salivary glands in 9 patients. Only 1 patient had clinically detectable mucosal lesions. However, in 5 of 6 patients with normal-appearing mucosa, histological examination revealed chronic inflammation. Three of the 10 patients had clinically atrophic and erythematous oral mucosa; histological examination again revealed chronic inflammation. The signs and symptoms appearing in the masticatory system of these 10 MCTD patients were many and varied and indicate the importance of closely examining all oral structures. As with other connective tissue diseases, MCTD should be treated on a multidisciplinary basis.

Quantitative immunohistologic and histomorphometric diagnostic criteria for Sjögren's syndrome

Sjögren's syndrome (SS) is a chronic auto-immune exocrinopathy, especially affecting the lacrimal and salivary glands. The aim of this study is to improve the diagnostic possibilities of the sublabial salivary gland (SSG) biopsy. The SSG biopsies of 19 patients with SS and 65 healthy control subjects were used in a quantitative immunohistologic and histomorphometric study. Statistical analysis of the immunohistochemical data resulted in a diagnostic criterion, which is based on the percentages of IgA- and IgG-containing plasma cells. Statistical analysis of 3 immunohistologic and 6 histomorphometric features resulted in a combined immunohistologic and histomorphometric criterion, which is based on 2 immunohistologic parameters (the percentages IgA- and IgG-containing plasma cells) and 3 histomorphometric parameters (the volume percentages of acini, intralobular ducts and diffuse lymphoplasmacytic infiltrate). The immunohistologic diagnostic criterion has a specificity of 95.4%, a sensitivity of 100% and an overall percentage of misclassification of 3.6%. The combined diagnostic criterion has a specificity of 98.5%, a sensitivity of 100% and an overall percentages of misclassification of 1.2%. Furthermore it reduces the number of false positive diagnoses with a factor 6 from 9% to 1.5%.

A new and highly sensitive immunohistologic diagnostic criterion for Sjögren's syndrome

Immunohistologic investigation of the sublabial salivary glands of 65 surgical patients who were free of systemic disease (control) and 19 patients with Sjögren's syndrome resulted in a new diagnostic criterion for SS that was more disease-specific than the widely used lymphocytic focus score criterion. Our bivariate classification criterion, which is based on the percentages of IgA- and IgG-containing plasma cells, has a specificity of 95.4% and a sensitivity of 100%, while its overall percentage of misclassification is 3.6%. This immunohistologic diagnostic criterion results in a reduction of the percentage of false-positive diagnoses from 9% to 4.6%.

General oral status in adults with rheumatoid arthritis

The oral status of an adult population of 204 patients with rheumatoid arthritis (RA) was compared with that of an age and sex-matched random sample of non-rheumatic subjects. The percentage of edentulous subjects, number of existing teeth in dentate subjects, prevalence, and quality of fixed and removable prostheses and prevalence of disorders of the stomatognathic system was recorded. The percentage of edentulousness among RA-patients was 17% and among non-RA subjects 19%. Number of remaining teeth was equal. 75% of removable partial and 62% of complete dentures among RA-patients were considered unsatisfactory compared to 25% and 56% respectively among non-RA subjects. Disorders related to the TMJ occurred much more frequently among RA-patients than among non-RA subjects. It is suggested that thorough stomatognathic examination and TMJ-prophylaxis be included in the overall care of RA-patients.

Sialochemistry in Sjögren's syndrome: a review

Sjögren's syndrome (SS) is an autoimmune exocrinopathy. The salivary glands are the site of activated T- and B-lymphocytes, along with gradual parenchymal destruction, diminished flow and altered composition of the secretory product. At present, sialochemistry has achieved no significance for the evaluation of SS patient. However, the number of sialochemical publications is steadily growing. This study review current sialochemical findings in patients with SS and relate the observations to the present concept of diagnosis, pathogenesis and prognosis of SS. An ideal combination of the collection of low-stimulated pure secretion, measurements of absolute flow-rates, and biopsy from the same glands seem to be unobtainable in SS patients. But two procedures may be appropriate: stimulated parotid secretion combined with parotid biopsies, or absorbance of low-stimulated labila saliva combined with labial gland biopsy. Sufficient data on disease-specific alterations in salivary composition in SS are still lacking. However, detection of specific changes in protein synthesis or in glycosylation as well as the detection of inflammatory cell products should be possible with the use of sensitive biochemical assays.

Oral candidiasis in Sjögren's syndrome: prevalence, clinical correlations, and treatment

Red, nonulcerated, uncomfortable oral mucosal lesions that are often thought to be caused by chronic xerostomia develop in some patients with Sjögren's syndrome (SS). However, we find that these lesions (1) clinically resemble chronic atrophic candidiasis (CAC), (2) usually yield Candida species from their surface, and (3) can be eliminated by topical antifungal drugs in spite of continuing xerostomia. In 246 patients who had primary or secondary SS, we correlated the presence or absence of atrophic oral mucosal lesions with the patient's salivary function and other clinical features. The 91 patients (37%) who had these lesions were older, had a greater frequency of primary SS and of oral symptoms, had had oral symptoms for a longer period, had more salivary gland inflammation, and had lower stimulated parotid flow rates than the 155 patients without CAC (p less than 0.05). However, unstimulated whole salivary flow rates and denture status were not significantly different. Topical antifungal treatment, begun on 47 patients, eliminated lesions in some. The methods of treating CAC are discussed. Candida-associated oral mucosal lesions do not develop in all patients with SS, but in susceptible patients, SS leads to a reversible form of CAC that is not associated with dentures.

Parotid gland enlargement and xerostomia associated with labial sialadenitis in HIV-infected patients

Infection with human immunodeficiency virus (HIV) may be associated with enlargement of the major salivary glands or symptoms of dry mouth. We term this condition HIV-associated salivary gland disease (HIV-SGD). In this report we describe 12 patients with HIV-SGD. Nine patients (one child, eight adults) had enlargement of the parotid glands, and three had xerostomia alone. Symptoms of dry mouth, dry eyes or arthralgia occurred in 11, five and five patients, respectively. Salivary flow rates were normal or slightly reduced in seven patients and severely reduced in five. Labial salivary gland (LSG) biopsy specimens from patients contained lymphocytic infiltrates in focal and other patterns, whereas specimens from three HIV-infected patients without salivary gland symptoms did not. The inflammatory infiltrates in LSG specimens showed a preponderance of T8-positive cells and a tissue T4/T8 average ratio of 0.66. The mean T4/T8 ratio of peripheral blood lymphocytes was 0.4. Serum antinuclear antibodies were present in one patient, but rheumatoid factor, SS-A, and SS-B antibodies were absent in all. Search for Epstein-Barr virus and cytomegalovirus in the LSG tissue of the six patients tested did not reveal evidence of antigens or DNA. HIV-SGD patients show a number of similarities to and differences from patients with Sjögren's syndrome (SS). The similarities include the oral and salivary features, histopathology and possibly changes in other organs. The differences include the lower salivary gland T4/T8 ratio and the absence of autoantibodies in serum. The causes of HIV-SGD as well as of Sjögren's syndrome are unknown.

Dry eyes or mouth--an epidemiological study in Swedish adults, with special reference to primary Sjögren's syndrome

The prevalence of dry eyes or dry mouth, and of primary Sjögren's syndrome (primary SS) according to the Copenhagen criteria were established in 705 randomly selected subjects, aged 52-72 years who answered a simple questionnaire, and of whom 247 (35%) reported symptoms. A subgroup with symptoms (n = 77) and a matched asymptomatic control group (n = 32) were examined with the Schimer-1 test (S1t), tear film break-up time (BUT), van Bijsterveld score (vB), unstimulated whole sialometry (Sialo) and, in about 40% of them labial salivary gland (LSG) biopsy and salivary gland scintigraphy. Apart from four cases of keratoconjunctivitis sicca (KCS) among controls, cases of KCS (15), xerostomia (12), autoimmune sialoadenitis (6) and primary SS (6) were exclusively confined to the symtomatic group. The calculated frequencies (with 95% confidence intervals) for the whole population were 14.9 (7.3-22.6)% for KCS, 5.5(3.0-7.9)% for xerostomia and 2.7 (1.0-4.5)% for autoimmune sialoadenitis and primary SS. The serum levels of ANA and RF were similar in the two groups, though those of anti-SS-B/La antibodies were higher in the group with symptoms (P less than 0.01).

Lymphocytic infiltrations of lip salivary glands in bone marrow recipients. A model for the development of the histopathological changes in Sjögren's syndrome?

By use of a PAP staining technique, the immunohistopathology in repeated biopsies from the lip salivary glands (LSGs) from patients undergoing bone marrow transplantation (BMT) was studied. In the previously normal LSGs, focally arranged lymphocytes and adjacent epithelial DR-expression appeared within 12 weeks post BMT, reaching a maximum between 26 and 52 weeks post BMT. Two years post BMT, lymphocytic infiltrates and epithelial DR-expression were still present in half of the specimens but were not seen in the remaining ones. The immunohistopathological changes seen in LSGs post BMT were indistinguishable from what has been found in Sjögren's syndrome. The appearance, and in some patients the subsequent disappearance, of the lymphocytic infiltrates and the epithelial DR-expression, without correlation to clinical symptoms of chronic graft-versus-host disease or immunosuppressive treatment, emphasizes the dynamic nature of lymphocytic infiltration of LSGs in BMT patients. Whether this also pertains to naturally occurring Sjögren's syndrome remains to be elucidated.

Clinical assessment and diagnosis of immunologically mediated salivary gland disease in Sjögren's syndrome

Because salivary gland function and morphology can be changed by a variety of diseases and drugs, the process of clinically assessing and diagnosing salivary gland changes in patients suspected of having Sjögren's syndrome (SS) must include not just clinical recognition of the problem and assessment of its nature and severity, but identification of the cause. Determining the presence of the salivary component of SS in a patient suspected of having the disease involves three types of observations: (1) eliciting symptoms and observing signs suggesting decreased salivary function (xerostomia) during the examination, (2) objectively assessing functional or anatomical salivary changes with different types of clinical procedures that are not necessarily disease-specific, and (3) applying the most disease-specific procedures as diagnostic criteria to determine the cause of the problem. Currently used diagnostic criteria for the salivary component of SS are reviewed and compared. Alternative diagnostic criteria should be avoided if they substitute non-specific tests for more disease-specific tests. There is as yet no perfect diagnostic criterion for the salivary component of SS, but significant focal sialadenitis in a labial salivary gland biopsy is the best in terms of its disease specificity, convenience, availability and low risk.

A postmortem study of focal adenitis in salivary and lacrimal glands

Investigations were carried out on 102 consecutive medicolegal post-mortem subjects to identify signs of focal adenitis in labial, submandibular, and lacrimal glands. There were 19 subjects (18.6%) with focus scores exceeding 1 in one or two of the types of glands. Among the 19, five had had a disease which is generally associated with Sjögren's syndrome or is autoimmune in nature. In another 63 subjects occasional lymphocytic foci were found in one, two, or all three types of gland. Fibrosis, atrophy, and fatty change had occurred most often in the labial salivary glands in those over 50 years of age with or without high focus scores. Fibrosis, atrophy, and fat infiltration had hardly ever occurred in the lacrimal glands, although this is the type of gland in which high focus scores occur most often. The results suggest that there may be a common autoimmune basis for Sjögren's syndrome and other diseases, the mechanisms of which are still incompletely understood. A focus score exceeding 1 may be an indicator of Sjögren's syndrome, but the diagnosis should not be established on the biopsy findings alone.

Epithelial HLA-DR expression in labial salivary glands in Sjögren's syndrome and non-specific sialadenitis

The expression of the Class II major histocompatibility antigen HLA-DR was quantified in the epithelial cells of labial salivary glands from patients with Sjögrens Syndrome (SS) and compared with similar expression in glands showing non-specific sialadenitis and normal controls. In all glands more duct cells were positive than acinar cells but only in sialadenitis and SS was strong epithelial staining seen. The proportions of duct and acinar cells expressing HLA-DR were increased between normals and sialadenitis (P less than 0.01) and between sialadenitis and SS (P less than 0.001). However, for all cases increased expression of HLA-DR correlated to the increased proportion of inflammatory cells in the gland (P less than 0.01). The results indicate that although HLA-DR is expressed on the epithelial cells in the glandular lesions of SS, this is not specific as it is also seen in sialadenitis. This supports the view that such expression is secondary to an inflammatory infiltrate and may not be of importance in initiating autoimmune tissue damage.

Ultrastructural study of Sjögren's syndrome-like disease in MRL/l mice

Salivary glands of autoimmune MRL/l mice were examined ultrastructurally and by immunoelectron microscopy to further characterize the Sjögren's syndrome-like disease in these animals. Major salivary glands from 12 female and 7 male MRL/l, two female MRL/n, and one female BALB/c mice were examined by electron microscopy and the glands from 4 female MRL/l mice were subjected to immunoelectron microscopy in order to detect Lyt-1 and Lyt-2 positive lymphoid cells. Mononuclear cell infiltrates were not seen in the salivary gland from the BALB mouse and occurred rarely in glands of MRL/n mice. However, in MRL/l mice, numerous lymphoid cells were present and acinar cells displayed low cytoplasmic density, cytoplasmic vacuolization and cellular lysis. Lymphoid cells were predominantly Lyt-1 positive although some Lyt-2 positive cells were observed. These results suggest that the MRL/l mouse represents a useful model for the study of the pathogenesis of Sjögren's syndrome in man.

Electrical stimulation of salivary flow in patients with Sjögren's syndrome

Patients with the salivary component of Sjögren's syndrome (SS) develop chronic xerostomia, which causes oral symptoms and functional impairment in approximate proportion to its severity. The purpose of this double-blind study was to determine whether an electrical stimulus applied to the tongue and hard palate by a battery-operated device (SAL II, Biosonics, Inc.) could stimulate salivary flow in subjects with generally severe SS. Twenty-nine patients with the salivary component of SS (diagnosed as the presence of focal chronic sialadenitis in a labial salivary gland biopsy specimen with a focus score of greater than 1 focus/4 mm2) were randomly assigned active or placebo devices, which they used for three minutes, three times a day for four weeks. Whole saliva flow rates were measured at weeks 0, 2, and 4 by collection of whole saliva both before and after stimulation with the device. Twenty-four subjects completed the study. The change in mean post-stimulation flow rate from week 0 to week 4 was greater for the 13 subjects using an active device (0.08 +/- S.D. 0.08 g/2 min, to 0.24 +/- 0.33 g/2 min) than for the 11 subjects using a placebo device (0.11 +/- 0.15 g/2 min, to 0.08 +/- 0.18 g/2 min) (p = 0.04). However, the magnitude of the mean difference was small, because three subjects using active devices responded and others did not. Only five subjects, all using active devices, reported a subjective increase in the amount of their saliva. The results of this study indicate that some SS patients with residual salivary flow show a significant response to electrical stimulation, but others with low or absent whole saliva flow rates do not respond.

Distribution and immunophenotype of the inflammatory cell population in the benign lymphoepithelial lesion (Mikulicz's disease)

Benign lymphoepithelial lesion (BLL) is an autoimmune process characterized by swelling and diffuse inflammation of the major salivary glands. Autoantibodies have been isolated from lymphocyte cultures obtained from affected salivary glands, but the pathogenesis is still unknown. Previous studies have shown that the predominant population of inflammatory cells is represented by helper T cells, with only brief mention of the B cell population. Twenty-five surgical specimens from patients with BLL were studied immunohistochemically. Antisera used included monoclonal antibodies LN-1 and LN-2 for B cells, LN-3 for cells expressing human leukocyte antigen-DR (HLA-DR) antigens, UCHL-1 for T cells, Leu-7 for natural killer (NK) cells, and T suppressor lymphocytes and the polyclonal antibody to S100 protein for dendritic cells. A peculiar distribution of the inflammatory infiltrate was observed in all cases, characterized by the presence of very irregular "germinal centers" with pseudopod-like extensions surrounding epimyoepithelial islands. Lymphoid cells in this location were reactive with LN-1 and LN-2 antibodies. These structures were surrounded by a "mantle" of mixed small B and T lymphocytes. A well-defined "interfollicular" zone was composed of cells strongly reactive with UCHL-1 and LN-3 antibodies, indicating the presence and activation of T cells. Dendritic cells defined by S100 and LN-2 reactivity were intermixed with epimyoepithelial cells, and were identified in 18 cases. Epithelial expression of HLA-DR antigens was restricted to inflamed areas. In contrast to previous reports denying the presence of Leu-7-positive cells in these lesions, cells reactive for this antibody were identified in 13 of 20 cases, predominantly within germinal centers. The presence of dendritic cells, complex organization of the inflammatory infiltrate into well-defined B cell proliferation centers and activated interfollicular T areas, and the abnormal expression of HLA-DR antigens in epithelial cells support an antibody-mediated destruction of the epithelial cells in this disease.

Comparison of parotid and minor salivary gland biopsy specimens in the diagnosis of Sjögren's syndrome

We conducted a prospective study comparing minor salivary gland and parotid gland biopsy specimens obtained simultaneously from 24 patients who were undergoing evaluation for primary Sjögren's syndrome (SS). Adequate tissue for study was obtained with all minor salivary gland biopsies and 19 of 24 parotid gland biopsies. Parotid inflammation was seen in 6 of 11 patients whose minor salivary gland biopsy results indicated SS, but in none of 8 patients who had normal findings on minor salivary gland biopsy. Patients with parotid inflammation were older and had a higher frequency of dry eyes and mouth, abnormal results on Schirmer's test, serious extraglandular involvement, and serologic abnormalities. We conclude that parotid gland biopsy adds very little to the minor salivary gland biopsy in the diagnosis of primary SS, but that parotid inflammatory changes may reflect disease duration and/or severity.

Clinicopathological study of myoepithelial sialadenitis and chronic sialadenitis (sialolithiasis)

To determine any overlap in pathological features between myoepithelial sialadenitis and chronic sialadenitis/sialolithiasis histological sections from 69 cases of myoepithelial sialadenitis (MESA) (n = 7) and chronic sialadenitis/sialolithiasis (n = 62) were reviewed over a 10 year period. Three of the cases with MESA contained calculi and four of those originally diagnosed as chronic sialadenitis/sialolithiasis showed epimyoepithelial island formation. The presence of calculi should not rule out a diagnosis of MESA, particularly in the parotid gland where calculi are uncommon; as the incidence of MESA may very well be underestimated and diagnosed as chronic sialadenitis, these patients, who are at increased risk of developing lymphoma, could be lost to follow up.

Diagnostic significance of salivary levels of beta 2-microglobulin in Sjögren's syndrome

To evaluate the diagnostic significance of salivary beta 2m in Sjögren's syndrome we measured salivary beta 2m levels in 19 patients with primary sicca syndrome (PSS), 15 with secondary Sjögren's syndrome (SSS) and compared the results with 20 normal healthy persons. We showed that beta 2m is specifically excreted in the saliva, because in normal saliva the concentration of beta 2m was unrelated to IgA levels. Also in normals, there was no relationship between serum and saliva concentrations of beta 2m. The mean saliva levels of beta 2m were increased in PSS (1.13 +/- 0.58) and SSS (1.39 +/- 0.69) compared with the levels in normals (0.53 +/- 0.22). The determination of beta 2m in the saliva can therefore be used as a noninvasive measurement for the confirmation of the diagnosis Sjögren's syndrome.

Acquired immunodeficiency syndrome mimicking Sjögren's syndrome and systemic lupus erythematosus

We describe a patient in whom the diagnosis of transfusion-associated acquired immunodeficiency syndrome (AIDS) was delayed because her clinical symptoms were similar to those of systemic lupus erythematosus and Sjögren's syndrome and because of a false-negative result on a Western blot test for human immunodeficiency virus. The importance of using different diagnostic tests for AIDS and the pitfalls in diagnosing AIDS in patients who appear to have connective tissue disease are discussed.

Focal adenitis in lacrimal and salivary glands. A post-mortem study

In the present study the submandibular, labial, and lacrimal glands of 102 postmortem subjects were studied as to the presence of inflammatory foci, fibrosis, atrophy and fatty change. Focal lymphocytic infiltration of these glands with focus scores exceeding 1, one of the findings on which the diagnosis of Sjögren's syndrome is based, was found in 19 cases (18.6%). Fibrosis, atrophy, and fatty change occurred most often in the labial salivary glands of patients over 50 years of age with or without high focus scores. Fibrosis, atrophy and fat infiltration hardly ever occurred in the lacrimal glands although this was the type of gland in which high focus scores occurred most often. The findings suggest that a wider than hitherto recognized spectrum of systemic inflammatory diseases may contribute to lymphocytic adenitis and degeneration of the exocrine glands. The diagnosis of Sjögren's syndrome should be confirmed by additional diagnostic tests.

Xerostomia due to Sjögren's syndrome. Diagnostic criteria, treatment and outlines for a continuous dental care programme and an open trial with Sulfarlem

The initial evaluation of 25 patients suspected of suffering from Sjögren's syndrome (SS) disclosed that sialopenia and glandular atrophy without focal sialo-adenitis was the second most common cause, after SS itself, of patient complaints. This emphasizes the importance of conclusive diagnostic criteria to prevent overdiagnosis and to form a sound basis for management of xerostomia patients. We found that at the time of diagnostic evaluation, the dental status of our SS patients did not differ from that of the normal Finnish population. This suggests that SS patients can greatly benefit from adequate dental care, assuming that attention is paid to early diagnosis and management. Accordingly, the diagnostic and therapeutic approach needs to be multidisciplinary. We present our current programme for oral and dental care of xerostomia patients and the results of an open trial with Sulfarlem (trithioparamethoxyphenylpropene) which was found not to be the drug of choice in the treatment of dry mouth associated with SS.

Evaluation of lip salivary gland biopsy in 21 patients with primary Sjögren's syndrome

Lip salivary gland biopsy was performed in 21 (20 female) patients, age 26 to 74 years, with primary Sjögren's syndrome. The procedure helped identify a patient group with many autoimmune phenomena, including hypergammaglobulinemia, autoantibodies, autoimmune thyroiditis, vasculitis, and immunocytoma. A marked association with the HLA-DR3 antigen was noted. It is concluded that lip salivary gland biopsy is a simple and safe procedure that makes possible the identification among non-RA patients with sicca symptoms those who have autoimmune disturbance. This patient group deserves close medical supervision in order to detect autoimmune disease that requires treatment, such as autoimmune thyroiditis and lymphoma.

Expression of HLA-D-locus (DP, DQ, DR)-coded antigens, beta 2-microglobulin, and the interleukin 2 receptor in Sjögren's syndrome

The expression of beta 2-microglobulin (beta 2m), class II major histocompatibility complex (MHC) antigens (HLA-DP, -DQ, -DR) and the interleukin 2 receptor (IL-2R) on resident and infiltrating cells in labial salivary glands of patients with Sjögren's syndrome (SS) was studied using an immunoperoxidase technique based on staining with monoclonal antibodies. The progression of the inflammatory process was accompanied by increasing numbers of immunocompetent cells as well as glandular epithelial cells expressing beta 2m and class II MHC antigens. Up to 60% of the infiltrating lymphocytes were DQ- and DR-positive while fewer cells stained for DP antigen. Glandular epithelium (acinar and ductal cells) stained for products of all three HLA-D subregions but with varying degrees of expression following the pattern DR greater than DP greater than DQ related to the severity of inflammation. A minor portion of the infiltrating lymphocytes expressed IL-2R. These findings emphasize the potential importance of epithelial expression of class II antigens in the local activation of T lymphocytes in salivary gland lesions of SS patients. They also indicate that differences may exist in this respect between T-cell reactions restricted by different class II MHC-encoded gene products.

Chronic anterior and posterior uveitis and primary Sjögren's syndrome

We examined eight patients with primary Sjögren's syndrome and uveitis. In all patients, the uveitis was bilateral, chronic, anterior and posterior, and not associated with active chorioretinitis. Seven of the eight patients were women. The diagnosis of primary Sjögren's syndrome was generally based on results of a Schirmer test, minor salivary gland biopsy, and serologic studies. Frequent findings included keratic precipitates, cataract, a pars plana exudate, an increased sedimentation rate, a positive test for antinuclear antibodies in a speckled pattern, and associated systemic disease compatible with the spectrum of Sjögren's syndrome.

Clinical studies of renal disease in Sjögren's syndrome

When 17 patients with Sjögren's syndrome, without apparent clinical manifestations of renal disease, were examined renal function studies frequently indicated abnormalities in their renal phosphate handling. The percentage tubular reabsorption of phosphate (%TRP) was decreased in six (35.3%), and maximal tubular reabsorption rate for phosphate (TmPO4/GFR) was low in eight (47.1%). In contrast, indices of renal calcium handling and serum parathyroid hormone levels were normal, suggesting that the abnormalities of phosphate metabolism were due not to extrinsic, but rather to intrinsic disease processes occurring in the kidney in Sjögren's syndrome. When the patients were divided into two groups according to the presence or absence of a renal tubular acidification defect (RTAD), patients with RTAD were younger (p less than 0.005), had longer disease duration (p less than 0.01), lower creatinine clearance (p less than 0.05), and higher incidence of low %TRP (p less than 0.05). Thus the patients with lower creatinine clearance generally had disease of longer duration at diagnosis and tended also to have defects in concentrating and acidifying the urine.

Paraneoplastic Sjögren's syndrome

A patient with primary Sjögren's syndrome preceding an oat cell carcinoma of the lung, is presented. Arguments to support a possible relationship between these two disorders are discussed.

T lymphocyte activation state in the minor salivary glands of patients with Sjögren's syndrome

Local lymphoplasmacytoid infiltration of the diseased exocrine glands is a cardinal sign of Sjögren's syndrome (SS). The state of T lymphocyte activation present in these local infiltrations was studied by three different techniques: determination of interleukin 2 (IL2) receptor (Tac) on cell surface membrane; autoradiography combined with immunoperoxidase staining of T cell epitopes; and electron microscopic analysis of the lymphoblast subclasses. Although 64 (SEM 4)% of the local inflammatory cells expressed Ia antigen, only 4 (SEM 1)% of them displayed the T cell activation antigen Tac. Autoradiography-immunoperoxidase double labelling showed that less than 1% of all T cells in situ were [3H]thymidine incorporating blasts. This finding suggests that although T lymphocyte is the dominant cell in situ, only a few of these cells have passed the G0/G1 interphase, and even fewer have been pushed to the S phase of the cell cycle by IL2. Transmission electron microscopy showed that few T blasts were present, even though there were many plasma cells. This result further confirms the impression that only a minor T cell subpopulation in situ is blast transformed despite the fact that many of the local T lymphocytes in the diseased salivary glands in SS are Ia positive.